Massachusetts Department of Elementary and Secondary Education 75 Pleasant Street, Malden, Massachusetts 02148-4906 Telephone: (781) 338-3700 TTY: N.E.T. Relay 1-800-439-2370 July 26, 2012 Robert J. Broudo, Executive Director Landmark School Day and Residential Programs 429 Hale Street Prides Crossing, MA 01965 Re: Mid-cycle Review and Verification of previous Program Review Corrective Action Plan Dear Mr. Broudo: Enclosed is the Department of Elementary and Secondary Education’s (“Department”) Midcycle Report based upon the Mid-cycle review conducted in your private school program in May 2012. This Mid-cycle Review Report contains the Department's findings regarding the implementation status and effectiveness of corrective steps taken in response to your previous Program Review Report issued on June 2, 2009. This report also includes a report on the status of implementation for new state or federal special education requirements enacted since your program’s last Program Review. We are pleased to indicate that the Department has found your program’s approved Corrective Action Plan to be substantially implemented and effective in remedying previously identified noncompliance issues. Additionally, we have determined that your program is in substantial compliance with any new state or federal special education requirements enacted since your last Program Review. You and your entire staff are to be congratulated for your efforts in implementing all necessary improvements. Your program will now receive an updated status of “Full Approval.” This approval shall remain in effect for three (3) years and will be contingent upon continued compliance with all regulations contained within 603 CMR 28.00 “Special Education Regulations” and 603 CMR 18.00 “Program And Safety Standards For Approved Public Or Private Day And Residential Special Education School Programs.” The Department may change this approval status at any point during this three-year period if circumstances arise that warrant such a change. The Department will notify you of your program’s next regularly scheduled Program Review Page 1 of 2 several months before it is to occur. At this time we anticipate the next routine monitoring visit to occur sometime during the 2014-2015 school year, unless the Department determines that there is some reason to schedule this visit earlier. Please be advised that the attached Department Approval Certificates must be conspicuously posted in a public place within the program as required by 603 CMR 28.09. Your staff's cooperation throughout these follow-up monitoring activities is appreciated. Should you require additional clarification of information included in our report, please do not hesitate to contact the Onsite Team Chairperson at 781-338-3713. Sincerely, Helen M. Murgida, Mid-cycle Review Chairperson Program Quality Assurance Services Darlene Lynch, Director Program Quality Assurance Services c: Mitchell D. Chester, Ed.D., Commissioner of Elementary and Secondary Education Nicholas Lopardo, Chairperson, Board of Directors Dan Ahearn, Local Program Review Coordinator Encl.: Mid-cycle Review Report Full Private School Approval Certificate, Expiration Date: August 31, 2015 Page 2 of 2 MASSACHUSETTS DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION PRIVATE SCHOOL MID-CYCLE REVIEW LANDMARK SCHOOL DAY AND RESIDENTIAL PROGRAMS MID-CYCLE REVIEW REPORT Previous Program Review Corrective Action Plan Submitted on July 2, 2009 Progress Reports Submitted on March 18, 2010, April 27, 2010 and May 19, 2010 Mid-cycle Onsite Visit Conducted on May 22 and May 23, 2012 Date of this Report July 26, 2012 Landmark School, Day Program and Residential Program, Mid-cycle Review Report July 26, 2012 Page 1 of 19 Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Selected Approved Private School Program Mid-cycle Review Criteria 2.2 Approvals, Licenses, Certificates of Inspection Documentation Observation 18.04(1); 28.09(2)(b)(5); 28.09(5)(b); 28.09(6)(b, c) 2.3 EEC Licensure 102 CMR 3.00 (Residential programs only) Documentation Landmark School Day and Residential Programs (Landmark School) submitted all current approvals, licenses, and certificates of inspection by state and local agencies as required. Not Applicable Landmark School Residential Program has a current, full license from the Department of Early Education and Care (EEC) (per 102 CMR 3.00) as required. Not Applicable Landmark School, Day and Residential Programs Mid-cycle Review Report July 26, 2012 Page 2 of 19 Criterion Number and Topic 8.5 Current IEP & Student Roster 28.09(5)(a) Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Partial Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Documentation At the time of the Mid-cycle Review, Landmark High School submitted a current IEP and student roster that contained all required elements. Student Records Interviews The Elementary/Middle School submitted a current IEP and student roster that contained all the required elements. Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Partial Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Landmark School Day and Residential Programs High School has 16 students with no evidence of IEPs and no parental signatures. By September 14, 2012 Landmark School Elementary/Middle School and High School must submit a current IEP and Student Roster that includes the following: o Each student’s initials (not name); o The school district responsible for preparing the student’s IEP; o The agency(ies) supporting any part of the student’s tuition; o The portion of tuition supported by such agency(ies); The Elementary/Middle School has one student with no evidence of an IEP and no parental signature. Landmark School, Day and Residential Programs Mid-cycle Review Report July 26, 2012 Page 3 of 19 Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting o o o o o 11.3 Documentation The Educational Administrator Landmark School, Day and Residential Programs Mid-cycle Review Report July 26, 2012 Page 4 of 19 The implementation date of the current IEP; The date of expiration for the student’s current IEP; The date of parental signature; The name of the school district contact person for each student; and For each unsigned IEP, evidence/ documentation of efforts and/or steps taken for the public school district to obtain signed IEPs. Not Applicable Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Educational Administrator Qualifications 28.09(5)(a); 28.09(7)(a); 603 CMR 44.00 Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance and his designees at the Elementary/Middle School and High School meet the required qualifications to serve in this position. Landmark School, Day and Residential Programs Mid-cycle Review Report July 26, 2012 Page 5 of 19 Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Criterion Number and Topic 11.4 Teachers (Special Education Teachers and Regular Education Teachers) 18.05(11)(f); 28.09(5)(a); 28.09(7)(b, c); 34 CFR 300.321 Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Partial Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Documentation Landmark School Day and Residential Program submitted current teacher rosters with all required elements. Staff Records Interviews Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Partial Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Seven Landmark School Day and Residential Program teachers have a “pending” license status; six teachers have “application submitted” status; and three teachers have an “in process” status. By September 14, 2012 Landmark School Day and Residential Programs Elementary/Middle School and High School must submit: Current teaching staff roster that includes all professional teaching staff in the private school program and that includes the following information: o The name, title and role of each teacher in the program; o Grade level being taught; o Subject(s) being taught; o Massachusetts teaching Landmark School, Day and Residential Programs Mid-cycle Review Report July 26, 2012 Page 6 of 19 Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting license title, type, grade level, number and expiration date; o Copy of ESE license or most current ELAR activity sheet; o In instances where teachers do not hold Massachusetts licensure for the area in which they are employed, a copy of a current certification waiver is provided or ELAR activity sheet; and o In instances when general education teaching staff are providing special education services, the name and license of the Landmark School, Day and Residential Programs Mid-cycle Review Report July 26, 2012 Page 7 of 19 Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting special educator providing supervision. 11.5 Related Services Staff Documentation Interviews 28.09(7)(d) 11.6 Master Staff Roster 28.09(7) Documentation Landmark School has submitted Related Service Staff Rosters for the Day and Residential Programs that contain all required elements showing that the provision of related services are being provided to students by appropriately certified, licensed or registered staff. Not Applicable Landmark School submitted a Master Staff Roster for the Day and Residential Programs that corresponds to the last approved Program Budget and that contains the name, Not Applicable Landmark School, Day and Residential Programs Mid-cycle Review Report July 26, 2012 Page 8 of 19 Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting A copy of students’ receipt of a copy of the school program’s antihazing disciplinary policy approved by the program’s Board of Directors was not found in student records. By September 14, 2012 For each of the five High School records that the Department reviewed onsite for the Mid-cycle Review, Landmark School must submit documentation of each student’s receipt of a copy of the school’s antihazing disciplinary policy approved by the program’s Board of Directors and a program job title, corresponding UFR title number, licensure and/or certification if appropriate, full-time equivalent (FTE), and qualifications for current staff as required. 19 Anti-Hazing M.G.L. c. 269, §§ 17 through 19 Partial Documentation Student Records Interviews Landmark School has an AntiHazing policy included in their student handbook. Partial Landmark School, Day and Residential Programs Mid-cycle Review Report July 26, 2012 Page 9 of 19 Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation 20 Bullying Prevention and Intervention M.G.L. c. 71, s. 37H, as amended by Chapter 92 of the Acts of 2010. M.G.L. c. 71, s. 37O (e)(1) & (2). M.G.L. c. 71, s. 370(d) Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Documentation Interviews Landmark School submitted a Bullying Prevention and Intervention Plan which included: a description of the process the program followed to amend its’ student admissions materials/handbook to include an age-appropriate summary of their Bullying Prevention and Intervention Plan; a description of how the Bullying Prevention and Intervention Plan information was distributed; and a description of the professional Landmark School, Day and Residential Programs Mid-cycle Review Report July 26, 2012 Page 10 of 19 copy of Landmark School’s procedure to ensure that all receipts are obtained as required. Not Applicable Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting development plan developed by the program for all staff for the school year and evidence of its implementation, that included dates, format(s) used and agendas. Identified Areas of Non-Compliance from the Previous Program Review or Other Areas of Concern 4.5 Immediate Notification 18.03(10); 18.05(7); 28.09(12)(a, b) Documentation Student Records Interviews At the time of the Program Review, a review of documentation and staff interviews indicated that while Landmark School had an approved policy regarding immediate notification of serious incidents to the Department of Elementary and Secondary Education the Landmark School, Day and Residential Programs Mid-cycle Review Report July 26, 2012 Page 11 of 19 Not Applicable Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting policy was not consistently implemented. Landmark School now provides immediate notification of serious incidents to the Department of Elementary and Secondary Education as required. 8.8 IEP – Progress Reports 28.07(3); 34 CFR 300.320(a)(3) (i, ii) Documentation Student Records Interviews At the time of the Program Review, a review of student records revealed that Landmark School provided comprehensive progress reports to parents and public school systems. However, reports generated at the High School level did not consistently identify individual Landmark School, Day and Residential Programs Mid-cycle Review Report July 26, 2012 Page 12 of 19 Not Applicable Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting goals listed on the IEP or reflect progress toward these goals. Landmark School now provides comprehensive progress reports to parents and public school systems that identify the goals listed on the IEP and reflect individual student progress toward these goals. 9.4 Physical Restraint (Day programs only) 18.05(5); 603 Documentation Interviews During the last Program Review, documentation review and staff interviews indicated that Landmark School had a written policy on physical restraint that included language as required by the Landmark School, Day and Residential Programs Mid-cycle Review Report July 26, 2012 Page 13 of 19 Not Applicable Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation CMR 46.00 Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Department. However, it also had a conflicting policy that stated it does not implement restraints “as a matter of policy”. While the student population at Landmark is not typical for the need for physical restraint as a common behavioral intervention, Landmark is required to have policies and procedures regarding implementation of restraints should the need arise. Landmark School now has policies and procedures regarding the implementation of restraints as required. Landmark School, Day and Residential Programs Mid-cycle Review Report July 26, 2012 Page 14 of 19 Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Criterion Number and Topic 12.1 New Staff Orientation and Training Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Documentation During the last Program Review, interviews indicated that new staff did not receive restraint training prior to their direct care duties with students as required. Staff Records Interviews Documentation Staff Records Interviews 28.09(7)(f); Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting 18.05(11)(g, i); 28.09(7)(f) 12.2 In-Service Training Plan and Calendar Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Documentation, staff records and interviews revealed that Landmark School now provides new staff restraint training prior to their direct care duties with students as required. During the last Program Review, documentation and interviews revealed that while several staff members have participated in the required extensive training for physical Landmark School, Day and Residential Programs Mid-cycle Review Report July 26, 2012 Page 15 of 19 Not Applicable Not Applicable Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation 28.09(9)(b); 28.09(10); 18.03(3); 18.05(9)(e)(1); 18.05(10); 18.05(11)(h) Title VI: 42 U.S.C. 2000d; 34 CFR 100.3; EEOA: 20 U.S.C. 1703(f); Title IX: 20 U.S.C. 1681; 34 CFR 106.31-106.42; M.G.L. c. 76, § 5; 603 CMR 26.00, esp. 26.07(2, 3) Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance restraint and intervention, such certifications had expired. Documentation, staff records and interviews revealed that appropriate staff have current restraint certification and have participated in physical restraint and intervention training as required. Landmark School, Day and Residential Programs Mid-cycle Review Report July 26, 2012 Page 16 of 19 Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation 15.5 Parent Consent and Required Notification Partial Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Some parents of Landmark School students have not completed the form regarding permission to restrain by approving or denying permission. By September 14, 2012 Landmark School must submit a student roster for the Elementary/Middle School and High School that includes the names of each student and the date of parental consent restraints, or submit evidence of documentation of follow up with the parents of students who have not responded. Documentation Student Records Interviews 18.05(5)(c); 18.05(8); 18.05(9)(f)(1); 18.05 (9)(j); M.G.L. c. 71, § 32A 16.7 Preventive Health Care Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified During the last Program Review based on a review of documentation and student records, Landmark School did not obtain annual consent for physical restraints as required. Partial Documentation, student records and interviews revealed that all parents receive a packet of information yearly on-line that includes a request for permission to restrain. Documentation Student Records Interviews During the last Program Review, Landmark School’s Health Center was found to have developed a Landmark School, Day and Residential Programs Mid-cycle Review Report July 26, 2012 Page 17 of 19 Not Applicable Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation 18.05(9)(g) M.G.L. c. 71, § 57 M.G.L. c. 111, § 111. Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance comprehensive form for annual physical examinations that included hearing, vision, and postural screening. However, student record reviews indicated that annual hearing screenings were not consistently documented in the student health record. Additionally, Landmark did not have a record of annual dental examinations on file for all day students as required. Student Records revealed that Landmark School now has hearing screenings for all students as required and a record of annual dental exams or documentation of efforts to Landmark School, Day and Residential Programs Mid-cycle Review Report July 26, 2012 Page 18 of 19 Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance obtain such exams for each student. Landmark School, Day and Residential Programs Mid-cycle Review Report July 26, 2012 Page 19 of 19 Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Commonwealth of Massachusetts Department of Elementary and Secondary Education LANDMARK SCHOOL DAY PROGRAM A PRIVATE SPECIAL EDUCATION PROGRAM OPERATED PURSUANT TO 603 CMR 18.00 AND 28.09 429 Hale Street Prides Crossing, MA 01965 Program Rate Based on: 275 Students Approved Enrollment: 257 Students Day Program Summer Program 10 month program Residential Program 11 month program 12 month program APPROVED STUDENT:LICENSED EDUCATOR RATIO: 8:1 APPROVED STUDENT:LICENSED EDUCATOR:AIDE RATIO: Not Applicable APPROVAL STATUS FULL APPROVAL Expires on: August 31, 2015 The current approval is a result of a Mid-cycle Review conducted in the 2011-2012 school year and the next review is scheduled for the 2014-2015 school year. HELEN M. MURGIDA, EDUCATIONAL SPECIALIST, PROGRAM QUALITY ASSURANCE SERVICES NINA M. MARCHESE, SUPERVISOR, PROGRAM QUALITY ASSURANCE SERVICES DARLENE A. LYNCH, DIRECTOR, PROGRAM QUALITY ASSURANCE SERVICES DATE ISSUED: 7/26/2012 Commonwealth of Massachusetts Department of Elementary and Secondary Education LANDMARK SCHOOL RESIDENTIAL PROGRAM A PRIVATE SPECIAL EDUCATION PROGRAM OPERATED PURSUANT TO 603 CMR 18.00 AND 28.09 429 Hale Street Prides Crossing, MA 01965 Program Rate Based on: 145 Students Approved Enrollment: 143 Students Day Program Summer Program 10 month program Residential Program 11 month program 12 month program APPROVED STUDENT:LICENSED EDUCATOR RATIO: 8:1 APPROVED STUDENT:LICENSED EDUCATOR:AIDE RATIO: Not Applicable APPROVAL STATUS FULL APPROVAL Expires on: August 31, 2015 The current approval is a result of a Mid-cycle Review conducted in the 2011-2012 school year and the next review is scheduled for the 2014-2015 school year. HELEN M. MURGIDA, EDUCATIONAL SPECIALIST, PROGRAM QUALITY ASSURANCE SERVICES NINA M. MARCHESE, SUPERVISOR, PROGRAM QUALITY ASSURANCE SERVICES DARLENE A. LYNCH, DIRECTOR, PROGRAM QUALITY ASSURANCE SERVICES DATE ISSUED: 7/26/2012